Is bed-wetting -- also known as "sleep enuresis" -- a sign of illness? Does it indicate a child is lazy or defiant? Trying to get attention? Suffering from behavior problems?
The answer -- in most cases -- is no.
Kids who wet the bed aren't lazy. Stress can contribute to enuresis, but most children who wet the bed don't have behavior problems.
And while bed-wetting can be caused by urinary tract infections and constipation, kids with these conditions tend to experience incontinence both night and day. If a child's only symptom is bed-wetting, disease is an unlikely cause.
Instead, researchers think the most important causes of bed-wetting are related to the physiology of nighttime urine control. A child's bladder might be overactive. The child might produce too much urine during the night. Or the child might sleep too deeply to awaken when he or she needs to urinate.
How should families respond to bed-wetting? Getting informed is the best first step. Here's a guide to common questions, and an evidence-based guide for coping with enuresis.
We aren't born with full bladder control. It takes time to develop. So bed-wetting is a normal part of early childhood. When does this change?
Studies suggest that most young children stop wetting the bed between the ages of 4 and 5. But some kids may achieve nighttime dryness even earlier. And a hefty percentage of 5-year-olds -- around 20% -- may still experience bed-wetting at least once per week (Kawauchi et al 2001; Butler et al 2005; Jansson et al 2005).
By convention, researchers typically define nocturnal enuresis as wetting the bed in individuals who are at least 5 years old (Franco et al 2013). But we shouldn't let this rule of thumb mislead us. It's not unusual for a 5-year-old to wet the bed on a regular basis.
One reasonable guess is that approximately 15-20% of kids in the early grades of primary school -- 6- and 7-year olds -- still wet the bed from time to time. As kids get older, the numbers diminish, so that by puberty the percentage of individuals wetting the bed is probably less than 5%.
But it's important to understand: Studies have reported a wide range of estimates -- from rates under 3% to rates exceeding 24%. And while some of the variation may reflect real differences between the groups being studied, a lot depends on what researchers count as bed-wetting.
For instance, some studies have counted anyone who wets the bed at least twice per month. Others have counted only those individuals who wet the bed at least twice per week. And as Richard Butler has shown, it makes a big difference.
In a study of more than 8200 British children (aged 7.5 years), Butler and his colleagues decided to measure bed-wetting both ways. While just 2.6% of kids wet the bed at least twice per week, more than 15% of children wet the bed at least twice per month (Butler et al 2005).
In another study, researchers reviewed the medical records of more than 1100 American children between the ages of 8 and 11. The researchers counted kids as having enuresis if either of these statements were true:
Using these standards, the researchers determined that about 4.5% of kids had a bed-wetting problem (Shreeram et al 2009).
So there isn't any one statistic that sums it all up. But however researchers measure enuresis, it's clear that bed-wetting isn't a rare or unusual problem.
Bed-wetting has been documented all over the world -- in Africa, the Americas, Asia, Australia, Europe, and the Middle East (e.g., Fockema et al 2012; Vasconcelos et al 2017; Tai et al 2007; Sureshkumar et al 2009; Butler and Heron 2008; Mohammadi et al 2019). And it persists even among adults.
For example, in surveys conducted in Hong Kong and South Korea, approximately 2.5% of respondents between the ages of 16 and 40 reported have at least occasional symptoms of nocturnal enuresis (Yeung et al 2004; Baek et al 2013).
Researchers recognize a number of possible causes. The most common include:
But doctors will look for different causes depending on a patient's history.
Some children achieve nighttime dryness during early childhood, and then develop a problem later. Doctors call this secondary nocturnal enuresis (SNE) -- bed-wetting in a child who was previously dry for at least 6 months.
When this kind of back-peddling happens, pediatricians want to make sure the child doesn't suffer from a new medical condition -- like a urinary tract infection or constipation.
Urinary tract infections can create a persistent urge to urinate. Constipation can put pressure on the bladder, so that the bladder’s capacity is greatly diminished (Caldwell et al 2005).
Secondary nocturnal enuresis (SNE) has also been linked with stress (Caldwell et al 2005), anorexia (Kanbur et al 2010; Kanbur et al 2011), and the onset of type 1 diabetes (Roche et al 2005).
This is called primary noctural enuresis (PNE), and it too can be linked with urinary tract infections, constipation, and stress (Robson et al 2005).
But researchers think that most cases are caused developmental factors relating to bladder function and/or sleep.
For instance, when it comes to bladder function, there is evidence that some kids have bladders that operate at reduced capacity during the night (Borg et al 2018).
Other children may have overactive bladders that leak before they are full (Nevéus 2019; Mattsson 2019).
And there's reason to think that some kids experience lower nighttime levels of vasopressin, a hormone that tends to suppress the production of urine. As a result, their bladders fill up faster -- increasing the risk of bed-wetting (Wille 1994).
First, there's a theory about arousal thresholds -- how hard it is to wake someone up.
When kids don't get enough sleep, their brains often try to compensate by sleeping more deeply when the opportunity arises. And deep sleep can increase the risk of bed-wetting. Kids aren't awakened by the sensations of a full bladder (Mattsson et al 2019).
So maybe some kids are wetting the bed because they suffer from too much disrupted sleep.
The idea gets support from a study that monitored children overnight using sleep polysomnography. The kids with enuresis experienced more fragmented sleep patterns, and they appeared to be harder to arouse (Soster et al 2017).
Another study -- combining physiological measures and parental sleep diaries -- reported that children with nocturnal enuresis tended to experience more night wakings and daytime tiredness (Cohen-Zrubavel et al 2011).
In addition, researchers noticed that approximately 50% of children's night wakings had been triggered by an episode of bed-wetting. Kids either woke up spontaneously after wetting the bed, or their parents woke them up (Cohen-Zrubavel et al 2011).
It's possible, then, that bed-wetting -- and the way families respond to bed-wetting -- could create a vicious cycle. Kids become sleep-deprived, which leads them to sleep so deeply that they wet the bed. Then the bed-wetting episodes trigger further sleep disruptions and sleep deprivation.
There's also reason to think that bed-wetting can be caused by obstructive sleep apnea.
Enuresis is more common in children who suffer from breathing abnormalities, like obstructive sleep apnea (Brown et al 2009; Kovacevic et al 2014; Jönson et al 2017; Wada et al 2018; Bascom et al 2019). And this link makes sense, because sleep-disordered breathing is known to cause hormonal changes that result in greater nighttime urine production (Umlauf and Chasens 2003).
So maybe some children experience bed-wetting as a side effect of their breathing problems. In support of this idea, researchers report that surgical treatments for severe sleep apnea are often followed by improvements in bed-wetting. Some kids stop wetting the bed after having their adenoids and tonsils removed (Jeyakumar et al 2012; Ding et al 2017).
Another possibility is that an underlying developmental factor triggers both sleep troubles and bed-wetting.
Researchers report that kids with nocturnal enuresis don't just awaken more often. They also experience more restless limb movements (Dhondt et al 2014; Dhondt et al 2015). So maybe there is something awry with the brain systems that control all of these phenomena -- sleep, nighttime muscle movements, and urination (Dhondt et al 2014; Dhondt et al 2015).
No. There is evidence that kids with behavior problems are more likely to experience urinary incontinence. But most children who wet the bed don't have these behavior problems.
For instance, children diagnosed with oppositional defiant disorder, or ODD, may be at higher risk for having bladder control problems, including nighttime enuresis. But most children who wet the bed don't have any symptoms of ODD (von Gontard et al 2015).
Similarly, kids diagnosed with ADHD (attention deficit hyperactivity disorder) are more likely to suffer from nocturnal enuresis (Shreeram et al 2009). But once again, most kids who wet the bed do not have ADHD.
So bed-wetting, by itself, is not a sign that your child suffers from any underlying behavioral or emotional problems.
That doesn't mean that psychological factors are irrelevant. As noted above, stress may be a contributing factor in some cases of bed-wetting. And it's clear that bed-wetting can cause distress. Kids with chronic bed-wetting problems suffer are more likely to suffer from low self-esteem (e.g., Collier et al 2002; Kanaheswari et al 2012; Grzeda et al 2017a).
But the old idea that bed-wetting is "psychological" has been debunked. Read more about it in my Parenting Science article, "Bed-wetting in scientific perspective."
Yes it does.
For instance, mothers who report having to urinate frequently during the night are more likely to have kids who wet the bed (Montaldo et al 2010). And kids are more likely to suffer from severe enuresis if they have one or more parent with a history of bed-wetting (von Gontard et al 2011).
Researchers speculate that certain traits -- like the amount of urine produced at night, or the tendency to sleep deeply -- might be controlled by our genes (Schaumburg et al 2008; Wang 2007).
It's possible. In particular, the early use of an approach called "elimination communication" (EC) has been linked with lower rates of bed-wetting.
In a survey of more than 18,000 parents, researchers in China found that children were less likely to experience nocturnal enuresis if they had begun elimination communication before the age of 6 months (Wang et al 2019).
Elimination communication demands that caregivers play close attention to their infants' signals. When it seems likely that a baby is ready to urinate, the caregiver holds the baby's bare bottom over a toilet and encourages the baby to void. You can read more about this technique here.
As noted above, it's important to treat any underlying diseases, infections, and sources of stress. But for most kids with primary nocturnal enuresis, these steps aren’t likely to solve the problem.
Currently, the therapies with the best evidence in their favor are:
Bed-wetting alarms use the same technology as diaper alarms. A moisture sensor is attached to the child’s underpants. When the child urinates, a sound awakens him.
How do these therapies compare?
In studies testing the effectiveness of alarms, kids slept with
bed wetting alarms every night for 12 weeks, and approximately half the kids
stopped wetting the bed (Glazener et al 2005).
The alarms seemed to work even better when training programs included an “overlearning” component, which means giving kids extra fluids before bedtime so that they have more opportunities to wake up and urinate (Glazener et al 2005).
Research indicates that desmopressin can yield similar results, with one important difference: Kids who use alarms are more likely to stay dry after treatment has concluded (Song et al 2019; Peng et al 2018).
Thus, studies favor the use of alarms -- if you can tolerate the fuss. Alarms are more disruptive, and for this reason, many families that try alarms give up on them.
This tactic, called "lifting," was tested in a randomized experiment on 4- and 5-year-olds, and there was a reduction in nocturnal enuresis symptoms after six months (van Dommelen et al 2009).
But more recently, researchers reported less encouraging news. In a study tracking more than 1250 bed-wetting children from the age of 7.5 years, lifting was not linked with long-term improvements. On the contrary, kids subjected to lifting were more likely to be wetting the bed two years later (Grzeda et al 2017b).
Lifting may be problematic because parents can't know for sure when a sleeping child needs to urinate. As a result, kids may be awakened when their bladders aren't full -- making it harder for children to learn to associate the sensations of a full bladder with a nighttime bathroom visit.
We need more research to be certain. Meanwhile, the available evidence suggests that lifting is less effective than alarms (Caldwell et al 2013), and possibly counterproductive.
Kids suffering from nocturnal enuresis don’t wet the bed on purpose. It's unfair to blame or punish them for bed wetting. And it appears to make things worse.
As noted above, kids who wet the bed may struggle with feelings of embarrassment, shame, or poor self-image about their condition (Collier et al 2002; Kanaheswari et al 2012; Grzeda et al 2017). And these emotional stresses could make it harder for children to develop bladder control (Glazier et al 2005).
For example, in a study of British children, parents who expressed displeasure in response to early bed wetting episodes were more likely to have kids who still wet the bed at age 7 ½ (Butler 2005).
Similarly, in studies conducted in Italy and the Netherlands, kids were less likely to improve if their parents punished them for nighttime accidents (Ferrara et al 2016; van der Wal et al 1996).
To date, there is little evidence that rewards are effective (Glazener et al 2005; van Dommelen et al 2009).
In fact, in one study, researchers found that offering rewards to 7.5-year-olds actually increased the risk of bed-wetting two years later (Grzeda et al 2017).
So I'm skeptical, and concerned about the message it might send.
When parents offer rewards to kids for staying dry at night, the implication is that bed-wetting is under conscious control.
But it’s not. Kids wet the bed while they are asleep. And I’d wager that most kids want us to understand. They are already motivated. They don’t need bribes. If they could wake themselves up, they would do it.
For more information about nocturnal enuresis, check out the article, Bed-wetting in scientific perspective: Destructive myths and misconceptions.
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Content of "Bed-wetting (sleep enuresis) in children" last modified 10/2019
Portions of this text appeared in a previous Parenting Science article, "Bed-wetting in children" (2010), posted at the same URL.
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image of human figure under the sheets by vaibhav ahuja / flickr